Specialization: Rehabilitation Psychology, WBSU

CASE HISTORY RECORD

Hospitals Registration no: Date first seen at Hospital:

Internship Guide's signature: C.H.R No- WBSU/10/CI

SOCIO -DEMOGRAPHIC VARIABLES

Identification details

Name:

Age:

Sex:

Address:

Telephone Number:

Mother Tongue:

Educational Qualification:

Occupation:

Religion:

Family Type: Nuclear/joint/Extended

Family size: Adults: Children:

Socio Economic Background:

Income:

a. Income Sources:

b. Family income:

INFORMANTS: (Name and Relationship with client)

Specialization: Rehabilitation Psychology, WBSU

Reliability, adequacy, consistency and corroborativeness of information

REFERRAL

● REFERRAL SOURCE :
● REASONS FOR REFERRAL:
CHIEF COMPLAINTS (In chronological order with duration)

History of present illness:

Onset:

Course:

Progress:

Predisposing factors:

Precipitating factors:

Perpetuating factors:
Specialization: Rehabilitation Psychology, WBSU

Background Information:

Significant information regarding present illness.

Biological functions:

Sleep- Appetite-

Energy-

Sexual interest and activity

Negative History:

Treatment history (for present illness)

Date Drug Dose Side Outcome Compliance

effects

(if any)

PAST HISTORY OF ILLNESS

● Medical illness :

● Psychiatric illness:

FAMILY HISTORY

Family tree
Specialization: Rehabilitation Psychology, WBSU

Consanguinity in parents:

FATHER MOTHER SIBLINGS

FATHER MOTHER SIBLING/S

Age

Living/ deceased

Education

Occupation

Family history of psychiatric illness /Mental Retardation/substance Dependence/Epilepsy

Family Interaction Pattern:

Communication:

Leadership:

Decision-making:

Family Rituals:

Cohesiveness:

Role:

Family Burden:

Expressed emotion:
Specialization: Rehabilitation Psychology, WBSU

PERSONAL HISTORY

Birth and developmental History (In my opinion in case of rehabilitation psychology birth
history should come before family history)

a) Term/ preterm/Post term

b) Type of birth
c) Duration of labour pain
d) Birth complications
e) Birth cry-Immediate/ Delayed/Weak
f) Birth weight
g) Significant prenatal factors
h) Significant perinatal factors
i) Significant neonatal factors (2 week after birth to 1 month)
j) Birth order
k) Milestone( If delayed then have to mention age of achievement)
l) APGAR score

Detailed developmental milestones to be noted for Child Cases

Age Motor Speech Vision and Social
hearing

m) Current Developmental status

Childhood Disorders:

School History:
Academic History Age of
school admission:
Highest grade completed:
Academic performance:
Specialization: Rehabilitation Psychology, WBSU

Reason for discontinuation:

Peer relationships:
Relationship with teachers:
Any disciplinary problems:
If there is any special school or classes

Hobbies & Interests:

Play Behaviour:

Present style of living:

Interpersonal relationships and social activities: (for Adult cases)

Occupational history: (for Adult cases)/ vocational history

Sexual history:

Marital history: (for Adult cases)

Specialization: Rehabilitation Psychology, WBSU

Family of procreation: (for Adult cases)

Habits and addictions:

Legal history:

General Temperament and character (attitude towards self and others responsibility talking ,
interpersonal relationship, sexual behavior, addiction.. – for child cases Premorbid
personality- (for Adult cases)

Behavioral observation

DOMAIN FINDINGS

Consciousness

General appearance

Psychomotor activity
Specialization: Rehabilitation Psychology, WBSU

Speech

Volition

Cognitive function
Attention and concentration

Orientation

Memory

General Intelligence

Judgment

Level of abstraction
Specialization: Rehabilitation Psychology, WBSU

Mood and affect

Thought

Perception

Child’s version of problem for child cases

Three wish test and animal test for child cases

Insight for adult cases

Any other observation

DIAGNOSTIC FORMULATION

PROVISIONAL DIAGNOSIS
Specialization: Rehabilitation Psychology, WBSU

Diagnosis POINTS IN FAVOUR POINTS AGAINST

DIFFERENTIAL DIAGNOSIS/DIAGNOSES

Diagnosis/ Diagnoses POINTS IN FAVOUR POINTS AGAINST

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Attended By Supervised By

Note: